About Heartburn, Gastroesophageal Reflux and
Gastroesophageal Reflux Disease (GERD)
When acid reflux occurs, food or fluid can be tasted in the
back of the mouth. When refluxed stomach acid touches the
lining of the esophagus it may cause a burning sensation in
the chest or throat called heartburn or acid indigestion.
Occasional GER is common and does not necessarily mean one
has GERD. Persistent reflux that occurs more than twice a
week is considered GERD, and it can eventually lead to more
serious health problems. People of all ages can have GERD.
The main symptom of GERD in adults is frequent heartburn,
also called acid indigestion—burning-type pain in the
lower part of the mid-chest, behind the breast bone, and in
the mid-abdomen. Most children under 12 years with GERD, and
some adults, have GERD without heartburn. Instead, they may
experience a dry cough, asthma symptoms, or trouble swallowing.
The reason some people develop GERD is still unclear. However,
research shows that in people with GERD, the LES relaxes while
the rest of the esophagus is working. Anatomical abnormalities
such as a hiatal hernia may also contribute to GERD. A hiatal
hernia occurs when the upper part of the stomach and the LES
move above the diaphragm, the muscle wall that separates the
stomach from the chest. Normally, the diaphragm helps the
LES keep acid from rising up into the esophagus. When a hiatal
hernia is present, acid reflux can occur more easily. A hiatal
hernia can occur in people of any age and is most often a
normal finding in otherwise healthy people over age 50. Most
of the time, a hiatal hernia produces no symptoms.
Distinguishing between normal, physiologic reflux and GERD
in children is important. Most infants with GER are happy
and healthy even if they frequently spit up or vomit, and
babies usually outgrow GER by their first birthday. Reflux
that continues past 1 year of age may be GERD. Studies show
GERD is common and may be overlooked in infants and children.
For example, GERD can present as repeated regurgitation, nausea,
heartburn, coughing, laryngitis, or respiratory problems like
wheezing, asthma, or pneumonia. Infants and young children
may demonstrate irritability or arching of the back, often
during or immediately after feedings. Infants with GERD may
refuse to feed and experience poor growth.
Talk with your child’s health care provider if reflux-related
symptoms occur regularly and cause your child discomfort.
Your health care provider may recommend simple strategies
for avoiding reflux, such as burping the infant several times
during feeding or keeping the infant in an upright position
for 30 minutes after feeding. If your child is older, your
health care provider may recommend that your child eat small,
frequent meals and avoid the following foods:
- sodas that contain caffeine
- spicy foods
- acidic foods like oranges, tomatoes, and pizza
- fried and fatty foods
Avoiding food 2 to 3 hours before bed may also help. Your
health care provider may recommend raising the head of your
child’s bed with wood blocks secured under the bedposts.
Just using extra pillows will not help. If these changes do
not work, your health care provider may prescribe medicine
for your child. In rare cases, a child may need surgery. For
information about GER in infants, children, and adolescents,
see the Gastroesophageal Reflux in Infants and Gastroesophageal
Reflux in Children and Adolescents fact sheets from the National
Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).
How is Acid Reflux / GERD treated?
See your health care provider if you have had symptoms of
GERD and have been using antacids or other over-the-counter
reflux medications for more than 2 weeks. Your health care
provider may refer you to a gastroenterologist, a doctor who
treats diseases of the stomach and intestines. Depending on
the severity of your GERD, treatment may involve one or more
of the following lifestyle changes, medications, or surgery.
- If you smoke, stop.
- Avoid foods and beverages that worsen symptoms.
- Lose weight if needed.
- Eat small, frequent meals.
- Wear loose-fitting clothes.
- Avoid lying down for 3 hours after a meal.
- Raise the head of your bed 6 to 8 inches by securing
wood blocks under the bedposts. Just using extra pillows
will not help.
Medications for Acid Reflux
Your health care provider may recommend over-the-counter
antacids or medications that stop acid production or help
the muscles that empty your stomach. You can buy many of these
medications without a prescription. However, see your health
care provider before starting or adding a medication.
Antacids, such as Alka-Seltzer, Maalox, Mylanta, Rolaids,
and Riopan, are usually the first drugs recommended to relieve
heartburn and other mild GERD symptoms. Many brands on the
market use different combinations of three basic salts—magnesium,
calcium, and aluminum—with hydroxide or bicarbonate
ions to neutralize the acid in your stomach. Antacids, however,
can have side effects. Magnesium salt can lead to diarrhea,
and aluminum salt may cause constipation. Aluminum and magnesium
salts are often combined in a single product to balance these
Calcium carbonate antacids, such as Tums, Titralac, and Alka-2,
can also be a supplemental source of calcium. They can cause
constipation as well.
Foaming agents, such as Gaviscon, work by covering your stomach
contents with foam to prevent reflux.
H2 blockers, such as cimetidine (Tagamet HB), famotidine
(Pepcid AC), nizatidine (Axid AR), and ranitidine (Zantac
75), decrease acid production. They are available in prescription
strength and over-the-counter strength. These drugs provide
short-term relief and are effective for about half of those
who have GERD symptoms.
Proton pump inhibitors include omeprazole (Prilosec, Zegerid),
lansoprazole (Prevacid), pantoprazole (Protonix), rabeprazole
(Aciphex), and esomeprazole (Nexium), which are available
by prescription. Prilosec is also available in over-the-counter
strength. Proton pump inhibitors are more effective than H2
blockers and can relieve symptoms and heal the esophageal
lining in almost everyone who has GERD.
Pro kinetics help strengthen the LES and make the stomach
empty faster. This group includes bethanechol (Urecholine)
and metoclopramide (Reglan). Metoclopramide also improves
muscle action in the digestive tract. Prokinetics have frequent
side effects that limit their usefulness—fatigue, sleepiness,
depression, anxiety, and problems with physical movement.
Because drugs work in different ways, combinations of medications
may help control symptoms. People who get heartburn after
eating may take both antacids and H2 blockers. The antacids
work first to neutralize the acid in the stomach, and then
the H2 blockers act on acid production. By the time the antacid
stops working, the H2 blocker will have stopped acid production.
Your health care provider is the best source of information
about how to use medications for GERD.
What if Acid Reflux / GERD symptoms persist?
If your symptoms do not improve with lifestyle changes or
medications, you may need additional tests.
Barium swallow radiograph uses x rays to help spot abnormalities
such as a hiatal hernia and other structural or anatomical
problems of the esophagus. With this test, you drink a solution
and then x rays are taken. The test will not detect mild irritation,
although strictures—narrowing of the esophagus—and
ulcers can be observed.
Upper endoscopy is more accurate than a barium swallow radiograph
and may be performed in a hospital or a doctor’s office.
The doctor may spray your throat to numb it and then, after
lightly sedating you, will slide a thin, flexible plastic
tube with a light and lens on the end called an endoscope
down your throat. Acting as a tiny camera, the endoscope allows
the doctor to see the surface of the esophagus and search
for abnormalities. If you have had moderate to severe symptoms
and this procedure reveals injury to the esophagus, usually
no other tests are needed to confirm GERD.
The doctor also may perform a biopsy. Tiny tweezers, called
forceps, are passed through the endoscope and allow the doctor
to remove small pieces of tissue from your esophagus. The
tissue is then viewed with a microscope to look for damage
caused by acid reflux and to rule out other problems if infection
or abnormal growths are not found.
pH monitoring examination involves the doctor either inserting
a small tube into the esophagus or clipping a tiny device
to the esophagus that will stay there for 24 to 48 hours.
While you go about your normal activities, the device measures
when and how much acid comes up into your esophagus. This
test can be useful if combined with a carefully completed
diary—recording when, what, and amounts the person eats—which
allows the doctor to see correlations between symptoms and
reflux episodes. The procedure is sometimes helpful in detecting
whether respiratory symptoms, including wheezing and coughing,
are triggered by reflux.
A completely accurate diagnostic test for GERD does not exist,
and tests have not consistently shown that acid exposure to
the lower esophagus directly correlates with damage to the
Surgery for Acid Reflux
Surgery is an option when medicine and lifestyle changes
do not help to manage GERD symptoms. Surgery may also be a
reasonable alternative to a lifetime of drugs and discomfort.
Fundoplication is the standard surgical treatment for GERD.
Usually a specific type of this procedure, called Nissen fundoplication,
is performed. During the Nissen fundoplication, the upper
part of the stomach is wrapped around the LES to strengthen
the sphincter, prevent acid reflux, and repair a hiatal hernia.
The Nissen fundoplication may be performed using a laparoscope,
an instrument that is inserted through tiny incisions in the
abdomen. The doctor then uses small instruments that hold
a camera to look at the abdomen and pelvis. When performed
by experienced surgeons, laparoscopic fundoplication is safe
and effective in people of all ages, including infants. The
procedure is reported to have the same results as the standard
fundoplication, and people can leave the hospital in 1 to
3 days and return to work in 2 to 3 weeks.
Endoscopic techniques used to treat chronic heartburn include
the Bard EndoCinch system, NDO Plicator, and the Stretta system.
These techniques require the use of an endoscope to perform
the anti-reflux operation. The EndoCinch and NDO Plicator
systems involve putting stitches in the LES to create pleats
that help strengthen the muscle. The Stretta system uses electrodes
to create tiny burns on the LES. When the burns heal, the
scar tissue helps toughen the muscle. The long-term effects
of these three procedures are unknown.
What are the long-term complications of Acid Reflux / GERD?
Chronic GERD that is untreated can cause serious complications.
Inflammation of the esophagus from refluxed stomach acid can
damage the lining and cause bleeding or ulcers—also
Scars from tissue damage can lead to strictures—narrowing
of the esophagus—that make swallowing difficult. Some
people develop Barrett’s esophagus, in which cells in
the esophageal lining take on an abnormal shape and color.
Over time, the cells can lead to esophageal cancer, which
is often fatal. Persons with GERD and its complications should
be monitored closely by a physician.
Studies have shown that GERD may worsen or contribute to
asthma, chronic cough, and pulmonary fibrosis.
For information about Barrett’s esophagus, see the
Barrett’s Esophagus fact sheet from the NIDDK.
Points to Remember about Acid Reflux
Frequent heartburn, also called acid indigestion, is the
most common symptom of GERD in adults. Anyone experiencing
heartburn twice a week or more may have GERD.
You can have GERD without having heartburn. Your symptoms
could include a dry cough, asthma symptoms, or trouble swallowing.
If you have been using antacids for more than 2 weeks, it
is time to see your health care provider. Most doctors can
treat GERD. Your health care provider may refer you to a gastroenterologist,
a doctor who treats diseases of the stomach and intestines.
Health care providers usually recommend lifestyle and dietary
changes to relieve symptoms of GERD. Many people with GERD
also need medication. Surgery may be considered as an acid reflux disease treatment.
Most infants with GER are healthy even though they may frequently
spit up or vomit. Most infants outgrow GER by their first
birthday. Reflux that continues past 1-year of age may in fact be GERD.
The persistence of GER along with other symptoms—arching
and irritability in infants, or abdominal and chest pain in
older children—is GERD. GERD is the outcome of frequent
and persistent GER in infants and children and may cause repeated
vomiting, coughing, and respiratory problems.
Hope through Research . . . The reasons certain people develop
GERD and others do not remain unknown. Several factors may
be involved, and research is under way to explore risk factors
for developing GERD and the role of GERD in other conditions
such as asthma and laryngitis.
» Please visit Chronic
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